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Global Health Policy Reducing Neonatal Mortality

Susan Niermeyer, MD, MPH, FAAP

Global Health Policy: Reducing Neonatal Mortality Objectives

• Understand the importance of neonatal mortality in under-5 child survival

• Define the challenges to reducing neonatal mortality globally

• Describe an initiative to reduce global neonatal mortality

Birth in Lushoto District, Tanzania

www.maweni.com/mimba

Regional rates of neonatal mortality

UNICEF, State of the World’s Children 2009

The world of early neonatal deaths (first 7 days)

www.worldmapper.org 2002

Millennium Development Goal 4 0

50

100

150

Glo

bal m

orta

lity

per 1

000

birt

hs

1960 1980 2000 2020 Year

Under-5 mortality rate

Late neonatal mortality

Early neonatal mortality

Target for

MDG-4

Lawn JE et al. Lancet 2005

Reduce under-5 child deaths 2/3 from 1990 levels by 2015

Timing of neonatal death Almost 50% of neonatal deaths occur in the first 24 hours

75% of deaths occur in the first week The time when most

newborns die is the time of lowest coverage with skilled attention

Lawn JE et al. Lancet, 2005

Global causes of neonatal death

Black R et al. Lancet 2010 Lee ACC, Wall SN, Cousens S et al.

BMC Public Health 2011

Landscape of perinatal death

Lawn JE, et al. PLoS 2011; 8:e1000389

The world of health workforce

www.worldmapper.org 2002

nurses midwives

physicians

Access to facility birth, trained staff, and resuscitation equipment

Wall SN, Lee ACC, Niermeyer S, et al. IJGO 2009; 107:S47

Births in facilities Attendant trained in neonatal resuscitation Equipment for resuscitation

Helping Babies Breathe evidence base and policy alignment • International Liaison Committee on

Resuscitation (ILCOR) – Neonatal Resuscitation: Consensus on Science and

Treatment Recommendations http://circ.ahajournals.org/cgi/content/full/ 112/22_suppl/III-91

• World Health Organization – Regional Technical Expert Review (Geneva) – Basic resuscitation guidelines (in revision) – Post-partum hemorrhage – Handwashing – Breast feeding

Action Plan Routine care The Golden Minute®

Advanced care

Helping Babies Breathe flipchart/simulator/learner workbook

Learner pair + neonatal simulator 6:1 learner-to-facilitator ratio

Demonstration and practice of separate skills

Facilitator demonstration and coaching of case scenarios in pairs

Peer learning/teaching

Case scenarios conducted independently by learner pairs

Extension of education and simulation to the clinical setting

• Clinical supervision

• Case audit

• Perinatal quality improvement

Bookman L et al. PAS 2009 2505.7

Singhal N, McMillan DD, Cristobal FL, et al. Health Care for Women Intl 2001; 22:569

Packages of interventions with evidence of efficacy/effectiveness

Helping Babies Breathe + • Essential Newborn Care • Integrated Management of Childhood and

Neonatal Illness • Neonatal Resuscitation Program • Integrated Management of Pregnancy and

Childbirth

Perinatal skills training

Clinical outcomes

• ↓death at 24 hours among babies not breathing at birth (RR = 0.46) with no change in stillbirths - Tanzania – N=6928/7277 pre/post training

• ↓ stillbirths (RR = 0.73) with no change in

neonatal deaths – India – N=4173/5427 pre/post training

Msemo G, PAS 2011 and Goudar S, GHC 2011

Education and community mobilization

Continuum of care from household to health system

Lawn JE, Lee ACC, Kinney M, et al. IJGO 2009; 107:S5

Empowerment of community health professionals and families

Women’s leadership expanding civic participation

Municipal officials increased advocacy for women

www.maweni.com/mimba

Community health workers training new cadres in the health system

Bang AT et al. J Perinatol 2005; 25:S72

Traditional birth attendants linking to the health system

Carlo W et al. NEJM 2010; 362:614 www.maweni.com/mimba

Continuum of care from household to health system

Lawn JE, Lee ACC, Kinney M, et al. IJGO 2009; 107:S5

HBB Global Development Alliance

•Overall Objective •Reduce newborn mortality due to asphyxia

•Guiding Principles •Inclusiveness and collaboration •Country-owned and country-led •Integration with maternal and essential newborn care •Shared goal, results, and recognition •Brand non-exclusivity

Financial and human resources

Indicator:

1. Funds mobilized for HBB implementation

Inputs Process Outputs Outcomes Impacts

Integrate HBB in national plan for essential newborn care and emergency obstetric and newborn care

Indicator:

2. HBB included in national newborn plan

Improved access, equity and quality of newborn resuscitation

Indicators:

3. Number of trainers trained by type of cadre & by district

4. Number and percent of birth attendants trained by type of cadre and by district

5. Number & percent of health facilities equipped with resuscitation devices by district

Improved survival

Indicator:

6. Number and percent of babies not breathing at birth that were resuscitated successfully

Optional indicators: 7. Resuscitated

successfully based on the key HBB action steps:

• Drying (stimulation) • Clearing the

airway/stimulation • Ventilation with bag and

mask

Improved health status

Indicator: 8. Rate of

intrapartum stillbirth and neonatal death (<24 hours)

Optional indicators: 9. Early NMR

(<7 days) 10.NMR (28

days) 11.Stillbirth

Prog

ram

Impl

emen

tatio

n

Vital registration Routine vital

statistics

Facility assessments (HMIS, SPA, QA/QI)* Quality, infrastructure, utilization, accessibility, service

readiness

Population-based surveys & surveillance (DHS/MICS, special surveys, sentinel surveillance)*

Service coverage, equity, mortality Dat

a so

urce

s HBB Monitoring and Evaluation Framework

Program Reports

HBB implementation - July 2011

www.helpingbabiesbreathe.org

Suggested reading

Oestergaard MZ et al. on behalf of the United Nations Inter-agency Group for Child Mortality Estimation and the Child Health Epidemiology Reference Group

Neonatal Mortality Level for 193 Countries in 2009 with

Trends since 1990: A Systematic Analysis of Progress, Projections, and Priorities

PLoS Medicine 8(8); e1001080. doi: 10.1371/journal.pmed.1001080

2009 NMR and % change in NMR 1990-2009

Oestergaard MZ et al. PLoS Med 2011 8(8):e1001080